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San Joaquin County o R <br />Environmental Health Department I U I L. <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202�1`nll I IV N(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd E�� L 'I <br />Well Permit Application <br />SCP _ 4 28196 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;_i'a I HEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is macs TTP_' ance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />p n /� �} Assesso <br />WELL Location S I S-7 W ��51✓�c55/tbPd o�iY•' i ross Street 1 j 4 City �r�C Zip i 3�G Parcel# //Vv <br />PROPERPROPERTt Alj J(� , y �. L p�y� �\ <br />Owner�Y(Address X71 (c{G^( �j ��. Cit > (� ��p Zi -f Phone# <br />C-57 Contractor /� // 11 ft�b Address ���L Cf �u City Ilrh(V10 Zip�S-7r/lLic _70SJ�/Pho((ne# n%- ll�7 <br />Consultant/ Sub Cntr ,h Cly Address `� 5 c7�L�c v �.� City ��lX Dict Lic# L�3U� �7 Phone#��l%C9 ) (-167 -/&� <br />GIS Coordinates: X Y Township Range Section <br />PE CODES <br />WORK TO BE PERFORMED: <br />AMOUNT REMITTED <br />-]�KtVEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />REC'D BY <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />INVOICE <br />`WELL # Nt w I A+- M l.J .T O PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />�y_1LA 1 <br />COMMENTS: <br />61 lltrl SR# 0�DtA- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />�v10NITORING •HOLLOW STEM DIA. OF BOREHOLE �•. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: „ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS -D; L10 TYPE OF CASING: 0 STEEL kPVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL fir TREMIE TYPE TO BE USED: ,Q'AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes j(No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS i f [ to G jlJ:2c Lu 4-1 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH S" BOLTED TRAFFIC BOX or 0 STOVE PIPE`— <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Cf/'1— <br />Signed x,�/1, Title/Company Li�G L�y�US/7C� 1�(/✓//l '0y vLna�ii{r, <br />Print Name f -I U 1/� I I I/Y1 ,in Date 30 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: '3UU <br />Application Accepted By 411Q, Date Issued S DL Area 36 <br />Grout Inspection By DatFinal Inspection By ate <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE ERMIT / SE UEST # <br />INVOICE <br />�y_1LA 1 <br />L', <br />61 lltrl SR# 0�DtA- <br />C-57 ✓ WCI%-WAIVERy" I/- C-57 Letter of Authorization to sign permitt,' Encro ��- <br />EHD 29-02-001 <br />6/22/04 <br />